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Tidak Nikah : .................
3.3 PENDIDIKAN: Tak Sekolah : ................. SD : .................
SMP : ................. SMA : .................
Diploma : ................. Univ. : .................
4. DOMISILI Di Kota : ................. Di Desa : .................
5. KONDISI EKONOMI: Bawah : ................. Menengah : .................
Atas : .................
III. KEGIATAN PERSAUDARAAN:
1. BIDANG PEMBINAAN: .........................................................................................
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2. BIDANG ORGANISASI: ........................................................................................
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3. BIDANG KERASULAN & HUBUNGAN: ............................................................
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4. BIDANG ADMINISTRASI / KESEKRETARIATAN: ..........................................
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5. BIDANG KEUANGAN: ..........................................................................................
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6. BIDANG LAIN-LAIN: ............................................................................................
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IV. PERMASALAHAN YANG TERJADI : .......................................................................
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V. USUL / SARAN : ...........................................................................................................
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Diisi oleh: Mengetahui, Minister:
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